Haemorrhoids

Question 1

What are haemorrhoids?

Answer 1

• aka Piles
• Enlarged, prolpased anal vascular cushions
• They are classified according to their size

Question 2

Describe the normal role of anal vascular cushions?

Answer 2

• Act to assist anal sphincter in maintaining continence
• There are three vascular cushions
  
  • Positioned at 3-, 7- and 11-o’clock positions
• When enlarged they are known as haemorrhoids

Question 3

What is the prevalence peak of haemorrhoids?

Answer 3

45-65 years

Question 4

Describe the different classifications of haemorrhoids?

Answer 4

• 1st degree:
  
  • Bleed, do not prolapse
• 2nd degree:
  
  • Prolapse during defecation but reduce spontaneously
• 3rd degree:
  
  • Prolapse during defecation but can be digitally reduced
• 4th degree:
  
  • Irreducibly prolapsed

Question 5

What are the main risk factors for haemorrhoids?

Answer 5

• Excessive straining / constipation
• Increasing age
• Raised intra-abdominal pressure
  
  • pregnancy, chronic cough, ascites

Question 6

What are the common clinical features of haemorrhoids?

Answer 6

• Painless bright red rectal bleeding
  
  • Commonly after defaecation, on paper or pan
  • *Blood is on the surface of stool, not mixed in
• Bleeding and prolapse are the cardinal features

Question 7

Differentials for haemorrhoids?

Answer 7

• Exclude other causes of rectal bleeding:
  
  • Malignancy
  • Inflammatory bowel disease
  • Diverticular disease
• Anal fissure
• Anal fistula
• Perianal abscess

Question 8

Investigations that should be performed in someone with suspected haemorrhoids?

Answer 8

• Proctoscopy to confirm diagnosis
• Prolonged bleeding may should warrant FBC and coagulation screen
• Flexible sigmoidoscopy or colonscopy to exclude malignancy in certain cases

Question 9

Complications of haemorrhoids?

Answer 9

• Thrombosis
  
  • Can cause secondary gangrene
• Ulceration
• Skin tags
• Perianal sepsis

Question 10

Describe the management of haemorrhoids?

Answer 10

• Mostly conservative
  
  • Increase fibre and fluid intake
  • Laxative
  • Topical lignocaine gel
• Non-surgical treatment
• Surgical treatment

Question 11

Describe the non-surgical interventions for haemorrhoids?

Answer 11

• Symptomatic 1st and 2nd degree haemorrhoids
  
  • Rubber-band ligation (RBL)
    
    • Haemorrhoid drawn out with suction gun then rubber band placed on its neck
  • Infrared coagulation
  • Photocoagulation

Question 12

What are the main complications of RBL?

Answer 12

• Recurrence, pain and bleeding
• If band is placed below the dentate line

Question 13

Describe the surgical management of haemorrhoids?

Answer 13

• Haemorrhoidectomy
  
  • Stapled or Milligan Morgan

Question 14

What are the main complications of a haemorrhoidectomy?

Answer 14

• Bleeding
• Infection
• Constipation
• Faecal incontinence

Question 15

Describe the pathogenesis of haemorrhoids?

Answer 15

• Degeneration of supporting fibroelastic tissue and smooth muscle
• With protrusion at the 3, 7 and 11 o’clock positions
• Prolapse of columnar epithelial component at later stages

Question 16

Waht positions will haemorrhoids be visible during proctoscope?

Answer 16

• Right anterior
• Right posterior
• Left lateral